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Osteoarthritis

Osteoarthritis

About Osteoarthritis

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Overview

Osteoarthritis is a painful condition in which joints become swollen and stiff. Cartilage is the soft tissue between the bones that meet at a joint. It acts as a cushion and allows your connecting bones to move smoothly without rubbing against each other. In people with osteoarthritis, the cartilage between bones begins to break down and the bones start grinding together. Osteoarthritis causes pain, joint swelling, and damage.

Don’t confuse osteoarthritis with other forms of arthritis, such as rheumatoid arthritis. Although the names sound similar, they are two very different diseases. Rheumatoid arthritis is an autoimmune disease in which the body attacks the lining of its own joints and causes inflammation (pain, redness, and swelling). It tends to worsen over time and can damage and deform the joints. It usually strikes people between the ages of 30 and 50. NSAIDs are sometimes used to relieve the pain and inflammation associated with rheumatoid arthritis. But the underlying disease often requires additional treatment with other kinds of drugs.

Common Symptoms

People with osteoarthritis usually have joint pain and stiffness. Unlike some other forms of arthritis, such as rheumatoid arthritis, osteoarthritis affects only joint function. It does not affect skin tissue, the lungs, the eyes, or the blood vessels.

The most commonly affected joints are those at the ends of the fingers (closest to the nail), thumbs, neck, lower back, knees, and hips.

Osteoarthritis affects different people differently. It may progress quickly, but for most people, joint damage develops gradually over years. In some people, osteoarthritis is relatively mild and interferes little with day-to-day life; in others, it causes significant pain and disability.

Although osteoarthritis is a disease of the joints, its effects are not just physical. In many people with osteoarthritis, lifestyle and finances also decline.

Lifestyle effects include:

depression

anxiety

feelings of helplessness

limitations on daily activities

job limitations

difficulty participating in everyday personal and family joys and responsibilities

What Causes it?

Osteoarthritis is the most common type of arthritis and is seen especially among older people. Sometimes it is called degenerative joint disease. Osteoarthritis mostly affects cartilage, the hard but slippery tissue that covers the ends of bones where they meet to form a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, small deposits of bone—called osteophytes or bone spurs—may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.

Am I at Risk?

About 27 million adults in the U.S. have osteoarthritis, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. It’s more common in older people, with up to a third of adults 65 and older suffering from the condition. Obesity also increases the risk of arthritis.

Although osteoarthritis becomes more common with age, younger people can develop it, usually as the result of a joint injury, a joint malformation, or a genetic defect in joint cartilage. Both men and women have the disease. Before age 45, more men than women have osteoarthritis; after age 45, it is more common in women. It is also more likely to occur in people who are overweight and in those with jobs that stress particular joints.

Consumer Reports Best Buy Picks

Naproxen (generic of Aleve, Anaprox, Naprosyn, Naprelan)

Cost: $4-$6/mo OTC, $46-$78/mo prescription

Ibuprofen (generic of Advil and Motrin)

Cost: $14/mo OTC, $15-$21/mo prescription

Both of these medications have been on the market for more than 20 years. Ibuprofen and naproxen are widely prescribed by doctors and are also used heavily (perhaps too heavily) as nonprescription pain relievers. Naproxen is not associated with increased heart risk. So for people at increased risk for heart attacks or strokes or a prior history of them, naproxen may be a better choice, especially if you take it frequently for a long period of time or at higher (prescription strength) doses.

Like other nonselective NSAIDs, both naproxen and ibuprofen are associated with increased risk of gastrointestinal bleeding. If you are at increased risk of bleeding due to older age, use of aspirin or other blood thinners, or a history of prior bleeding or ulcers, talk to your doctor before starting an NSAID. Celecoxib (Celebrex) may be an alternative in some situations. You may be able to take an acid blocker to help protect the stomach.

Celecoxib is no more effective at relieving pain than ibuprofen or naproxen, but is more expensive, so it is not a top choice drug for most people. For people with a very high bleeding risk, even taking Celebrex or using an acid-blocker may not make taking an NSAID safe, so discuss alternative treatments for pain with your doctor.

If you need higher doses of an NSAID due to osteoarthritis or other conditions, your best bet is to get a prescription NSAID under a physician’s care. He or she should monitor your response and your risk of any side effects, including stomach, heart, and kidney problems.

If your pain is localized to one or a few joints or muscles, one of the topical formulations—gel (Voltaren), drops (Pennsaid), or patches (Flector)— might be good options to consider. But they aren’t cheap: A month’s supply can cost between $196 and $478 or even more, depending on how much and how often they are applied. Although the idea of these topical formulations was to reduce the risk of ulcers and gastrointestinal bleeding, this has not yet been proven definitively, though the medications do cause less stomach upset. And since the topicals result in reduced levels of the NSAID medication in the body, they should theoretically pose a reduced risk of heart attack and stroke, but studies are needed to confirm this. So unless you need the convenience of a patch, drops or gel, and are willing to pay the extra cost, for most people a pill is still your best bet.

For occasional use—for example, if your arthritis or pain symptoms are mild or intermittent—you can probably get the pain relief you need by taking nonprescription aspirin, ibuprofen, or naproxen.

Our advice

If you have had a stomach ulcer or bleeding, or are at high risk of either, talk with your doctor about the potential risks of taking NSAIDs and treatment alternatives. The risk of bleeding from NSAID use increases with age.

If you have heart disease or are at risk of a heart attack or stroke, talk with your doctor about the potential risks of taking any NSAID.

If you have kidney disease or high blood pressure, talk with your doctor about the risks of taking NSAIDs for long periods of time.

Take the lowest dose of an NSAID that brings relief and do not take any longer than necessary.

NSAIDs can interact with other medicines, including other NSAIDs, such as aspirin, and increase the risk of serious side effects. If your doctor prescribes an NSAID, tell him or her about any other medicines or dietary supplements you are taking, including daily aspirin to reduce your risk of heart attack or stroke.

NSAIDs are effective pain relievers. But even the nonprescription forms like ibuprofen (Advil, Motrin IB, and generic) and naproxen (Aleve and generic) can be dangerous when taken too often or in high doses regularly.

Although there are no studies that quantify the extent of the inappropriate or unsafe use of NSAIDs, many doctors and our medical consultants think that Americans overuse them, taking both the nonprescription and prescription versions too often for mild headaches and everyday aches and pains, especially those associated with exercise and sports.

Given that, we offer the following recommendations to reduce your risk:

Don’t take NSAIDs on a regular basis to treat osteoarthritis or chronic pain without seeing a doctor to assess your risk for heart problems and gastrointestinal bleeding.

Are they Safe?

When applied to the population as a whole, NSAID related deaths are substantial. The Arthritis, Rheumatism, and Aging Medical Information System estimates that adverse effects due to NSAIDs may be responsible for more than 100,000 hospitalizations and more than 16,000 deaths in the U.S. each year.

Stomach Ulcers and Gastrointestinal Bleeding

Celecoxib (Celebrex), the only COX-2 selective NSAID available in the U.S., has consistently shown an advantage in lowering the risk of serious ulcer complications in the short-term (six months or less) compared with other NSAIDs. Although one major study that compared Celebrex with two other NSAIDs—ibuprofen and diclofenac—over a year found that overall, Celebrex was not any less likely to cause serious ulcer complications, analyses of all of the available studies indicate that Celebrex is effective at reducing the risk of ulcers with longer-term use.

For certain people with osteoarthritis who are at a higher risk of stomach ulcers and bleeding—due to being over 60, taking additional medication, such as aspirin, which is also known to cause stomach problems, or having a history of stomach ulcers and bleeding—current guidelines on pain management recommend either dual treatment with an NSAID plus an acid-reducing medication, such as a proton pump inhibitor (PPI), or treatment with celecoxib (Celebrex), possibly with a proton pump inhibitor. Because even these strategies may not reduce the risk of bleeding to safe levels in someone at high risk, it’s important to talk to your doctor before taking an NSAID.

A majority of studies found that dual treatment with an NSAID plus a proton pump inhibitor was fairly similar to celecoxib (Celebrex) in the reduction in risk of ulcer complications in the upper GI tract of highrisk patients. One large observational study did find an advantage for celecoxib when it was compared to diclofenac plus a different kind of acid reducing medication, misoprostol, in people who were 66 or older. Celebrex was less likely to cause dangerous upper GI bleeding than diclofenac plus misoprostol.

In patients with a recent bleeding ulcer, the risk of rebleeding is high with either celecoxib or a nonselective NSAID. Based on a recent randomized trial, the best strategy in this situation would be celecoxib plus a proton pump inhibitor, if an NSAID is used.

Compared to taking an NSAID alone, studies also show that adding an acid-reducing medication (such as a PPI, an H2 receptor antagonist, or misoprostol) to an NSAID reduces the risk of “endoscopic ulcers.” One acid-reducing medication, misoprostol (Cytotec and generic), has been shown to reduce short-term risk of serious ulcer complications in older patients taking NSAIDs for rheumatoid arthritis. But, since there are no longer-term studies, how well they work beyond six months is unknown.

In addition, misoprostol has to be taken four times a day and is difficult for many patients to tolerate because of GI side effects like nausea, vomiting, and diarrhea. PPIs have fewer side effects, only need to be taken once or twice daily, are stronger acid blockers than H2 receptor antagonists—such as famotidine (Pepcid AC and generics) and ranitidine (Zantac 150 and generics)—and some are available over-the-counter. Because of that, PPIs are currently the main acid-reducing medication used to prevent ulcers related to NSAIDs.

One trial evaluated whether adding a PPI to celecoxib (Celebrex) would provide even more protection from stomach ulcers and bleeding than taking celecoxib alone after hospitalization for upper GI bleeding. The addition of the PPI esomeprazole (Nexium) to celecoxib reduced risk of recurrent GI bleeding over 13 months following initial hospitalization.

Although based on the results of several older observational studies, salsalate has often been considered to be easier on the stomach and gastroinstestinal tract than other NSAIDs, the analysis upon which this Best Buy Drug report is based considers the strength of evidence with these studies to be low because they had several limitations. The studies did not take into account whether people who participated were taking other medications or had other medical conditions. The studies also did not clearly define how they assessed toxicity, how they selected people to participate, or how long the people were followed after taking salsalate.

One of the primary ideas behind the development of topical NSAIDs was to minimize the risk of serious ulcer complications by reducing the amount of the medication circulating in the body, since topical NSAIDs produce lower blood levels of the drug than oral NSAIDs. But so far, no randomized, controlled trial has evaluated the long-term risk of serious ulcer or stomach-bleeding complications with the topical forms of diclofenac. Only one short-term study found that compared to oral diclofenac, topical diclofenac (Pennsaid) lowered—by 66 percent—the risk of “severe” gastrointestinal events—those that produced impairment or incapacitation and were a clear hazard to the patient’s health. But the advantage of topical diclofenac beyond 12 weeks has not yet been evaluated in a randomized trial. In an observational study based on a well-known database in the U.K., topical NSAIDs were associated with lower risk of GI bleeding than oral NSAIDs, but more research is needed to verify this finding. Diclofenac is the only NSAID available in FDA approved topical formulations, to date.

Heart Attacks and Strokes

All NSAIDs carry a warning on their labeling that if used in certain ways they have the potential to raise the risk of heart attacks and strokes.

So far, for the older, nonselective, nonaspirin NSAIDs, a meta-analysis of primarily short-term trials found that all except naproxen were associated with similar increased risks of heart attack compared with placebo. Celecoxib (Celebrex) has also been found to increase the risk of heart attack compared to placebo, though most of the trials evaluated patients taking celecoxib for colon polyp prevention or for prevention of Alzheimer’s disease, not for treating osteoarthritis. The trials generally evaluated higher doses of NSAIDs. Taking all of the available studies together, all NSAIDs, besides aspirin and naproxen, appear to nearly double the risk of heart attacks and related complications.

No randomized controlled trial has evaluated the risk of heart attacks and strokes with topical NSAIDs.

Hypertension, Heart Failure, and Kidney Problems

NSAIDs can aggravate high blood pressure, which is one way they could raise the risk of heart attack. They cause fluid retention, which can lead to slight weight gain or swollen legs even in healthy individuals. In people who have a “weak heart” (due to congestive heart failure or left ventricular dysfunction), fluid retention due to NSAIDs could make your symptoms worse and increase your risk of being sent back to the hospital if you have previously been hospitalized for heart failure.

NSAIDs also reduce kidney function in some individuals, especially those who already have kidney disease from diabetes or other causes. The risk of these problems is similar for different NSAIDs.

No randomized, controlled trial has evaluated the risk of hypertension, heart failure, and kidney problems with topical forms of diclofenac.

Liver Problems

All products containing diclofenac carry a warning that they can increase the risk of abnormal liver-function tests. And there have been some reports to the FDA about cases of severe liver damage and related deaths that occurred in people taking oral diclofenac. Although a 2005 systematic review of 65 published and unpublished short-term randomized controlled trials found a 3.5-fold increase in risk of abnormal liver-function tests with oral diclofenac compared with a placebo, the degree of increased risk of clinical issues (such as liver failure) is much less certain. So far, only one published study has evaluated the long-term risk of serious liver problems due to diclofenac. That study looked at more than 17,000 patients who took oral diclofenac over 18 months and did not find any cases of liver failure, transplant, or death.

As for topical NSAIDs, short-term trials found that the risk of abnormal liver-function tests were reduced with the diclofenac topical solution (Pennsaid) compared with oral diclofenac over 12 weeks. But no randomized, controlled trial has evaluated the long term risk of serious liver problems with any of the topical forms of diclofenac.

Fracture

The risk of bone fractures with NSAIDs is uncertain. In 2006, preliminary evidence emerged from a large observational study that found that ibuprofen, diclofenac, and naproxen were associated with an increased risk of fracture. However, there are several drawbacks to this study. One is that it is unclear whether the increase in fractures was due to actual weakening of the bone structure, changes in balance, increased clumsiness, or something else entirely. More studies are needed to better assess the relationship between NSAIDs and fracture risk.

Tolerability

Oral NSAIDs can cause other minor side effects, including upset stomach, abdominal pain, and diarrhea. Their frequency is about the same no matter which NSAID you take. About one in five people who take prescription doses of oral ibuprofen, naproxen, or diclofenac regularly, for example, have experienced one of these side effects, according to an analysis done by the Oregon Health & Science University’s Drug Effectiveness Review Project, or DERP. However, most people taking the older oral NSAIDs don’t stop taking the medicine because of side effects. Oral NSAIDs can also cause skin rashes, but these are rare.

With topical NSAIDs, one of the most common side effects is irritation of the skin where the drops, gel, or patch is applied. For diclofenac topical solution (Pennsaid), dry skin at the application site was the most common type of skin irritation and occurred in up to 36 percent of the adults treated for osteoarthritis. The risk of dry skin at the application site with diclofenac topical solution was 30 times greater than with a placebo.

In contrast, skin irritation might not be as much of a problem with diclofenac gel (Voltaren gel). Overall, application-site reactions only occurred in four to five percent of the patients using the topical gel for osteoarthritis of the hand or knee, which was only slightly higher than the two percent of patients using a placebo. However, it remains unclear whether the gel offers any real side effect advantage over the solution.

Age, Race, and Gender Differences

Age is an important factor when considering NSAID treatment, especially long-term. The risk of GI bleeding and stomach ulcers with oral NSAIDs increases with age, as seen in Table 4 on page 19. So does heart disease risk. The older you are the more cautious your doctor should be in treating you with NSAIDs for long periods of time. Some doctors now routinely prescribe a stomach acid reducer to people 65 and over taking an oral NSAID.

There is scant data on any differences by gender or race in response to oral NSAIDs. But an important recent study found that aspirin’s heart- and strokeprotective effect was different in men and women. It found that while women taking low-dose aspirin regularly had fewer strokes than men, they did not get the same benefit as men in preventing a first heart attack. The reason for this difference is unknown. It raises the possibility that women and men might also respond differently to other NSAID drugs.

Whether there are any differences in the benefits and risks of topical NSAIDs based on age, race, or gender is not yet known because their effects in patient subgroups have not yet been evaluated in any studies.

Are there Over-the-Counter Options?

The following drugs are also available over the counter:

Aspirin, Bayer, Bufferin (acetylsalicylic acid)

Advil, Motrin (ibuprofen)

Aleve, Anaprox, Naprosyn, Naprelan (naproxen)

Are there Non-Drug Options?

Surgical Options

For many people, surgery helps relieve the pain and disability of osteoarthritis. Surgery may be performed to achieve one or more of the following:

Removal of loose pieces of bone and cartilage from the joint if they are causing symptoms of buckling or locking (arthroscopic debridement).

Repositioning of bones (osteotomy).

Resurfacing (smoothing out) bones (joint resurfacing).

Surgeons may replace affected joints with artificial joints called prostheses. These joints can be made from metal alloys, high-density plastic, and ceramic material. Some prostheses are joined to bone surfaces with special cements. Others have porous surfaces and rely on the growth of bone into that surface (a process called biologic fixation) to hold them in place. Artificial joints can last 10 to 15 years or longer. Surgeons choose the design and components of prostheses according to their patient’s weight, sex, age, activity level, and other medical conditions.

Joint replacement advances in recent years have included the ability, in some cases, to replace only the damaged part of the knee joint, leaving undamaged parts of the joint intact, and the ability to perform hip replacement through much smaller incisions than previously possible.

The decision to use surgery depends on several factors, including the patient’s age, occupation, level of disability, pain intensity, and the degree to which arthritis interferes with his or her lifestyle. After surgery and rehabilitation, the patient usually feels less pain and swelling and can move more easily.

Exercise

Research shows that exercise is one of the best treatments for osteoarthritis. Exercise can improve mood and outlook, decrease pain, increase flexibility, strengthen the heart and improve blood flow, maintain weight, and promote general physical fitness. Exercise is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise prescribed will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done. Walking, swimming, and water aerobics are a few popular types of exercise for people with osteoarthritis. Your doctor and/or physical therapist can recommend specific types of exercise depending on your particular situation.

Weight Control

If you are overweight or obese, you should try to lose weight. Weight loss can reduce stress on weight-bearing joints, limit further injury, increase mobility, and reduce the risk of associated health problems. A dietitian can help you develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Prevention

The best way to ward off the pain, stiffness, and joint “creakiness” of osteoarthritis and aging is regular exercise, stretching, muscle strengthening, and losing weight if necessary. In some cases, keeping active and limber can eliminate or sharply reduce the need to take medicine. But be careful: Some exercises might be inappropriate for your condition and you can injure yourself if you do an exercise incorrectly. Ask your doctor or physical therapist to help you develop an appropriate and safe exercise program.

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